The Electronic Medical Record Mandate and Managing Fraud: More Government Ineptness?

The Obama administration has clearly mandated that Electronic Medical Records (EMR) will be necessary in order to comply with Federal regulations for reimbursement for both hospitals and physicians.  The transition to EMR is an important step towards streamlining patient care–however, the current implementation of EMR is fraught with complications, workflow issues and system wide “bugs”.  At this point in the US there are numerous EMR systems and no absolute standard which continues to make communication between different hospital systems and physicians difficult at times.  I realize that the EMR mandate has spanned more than one administration and let me state at the very outset that I am 100% FOR the implementation of an electronic medical record system–However, I would like to see the transition be done in a stepwise, intelligent way that allows for universal portability within the US.   Moreover, the EMR should be electronically available to all patients via smartphone and tablet download from the mysterious (and hopefully secure) “cloud”.

The EMR when properly managed can provide detailed notes that are easily applied to templates for billing medicare and medicaid documentation (it allows MDs to correctly bill the level of service based on comparison of the patient’s newly created chart note to standards for required components).  However, the time involved in documenting via EMR (especially in the transition phase in a busy practice) can be overwhelming.  Physicians and other providers are already overwhelmed with offices full of patients–longer hours, more appointments and loads of new paperwork. The Affordable Care Act (ACA) promises to add loads of newly insured sick patients to the practice workload.  Add to that a cumbersome computer system and it is likely that errors will occur.

This week in the New York Times, Abelson and Creswell report on the new Department of Justice focus on EMR fraud activities.  The Office of Inspector General (OIG) for HHS released a report on Tuesday (the second in two months) warning of the potential widespread fraud and abuse occurring as a result of EMR implementation.  The warning specifically cites a lack of oversight and safeguards in the Federal government to prevent these from occurring.  The government has already spent nearly $22 Billion dollars on the push for conversion from paper to EMR in the US.  (sound familiar?  rapid roll out of new technology without proper evaluation).

According to the New York Times report, the central issue with the EMR and potential fraud has to do with the lack of regulations surrounding the common practice of “copy and paste” known as “cloning”.  For many physicians, the ability to cut and paste data and information from one place to another in a note or within a patient’s particular chart can significantly improve efficiency and reduce the amount of time that is spent inputting redundant data into a patient’s record.  Critics of this practice, including the OIG, suggest that in many cases the importation of data from note to note or chart to chart results in “overbilling” for services that were not in fact rendered.  For example, if a chart note from a follow-up visit of moderate complexity  is “cloned” with data from a previous visit where the level of service was more extensive than the current visit, then charges may be filed for an level of complexity that was not, in fact, provided.  The OIG statement goes on to warn that their “level of involvement in EMR cases [will] increase” and that dealing with documentation “fraud” via cloning in EMR will become a “top priority”.  In a survey conducted by HHS and released in a previous report, the OIG found that very few hospitals and medical practices have any guidelines or restrictions on “cloning” notes for documentation.

Once again, in my opinion, our government has missed its mark.  Instead of carefully creating a universally acceptable and streamlined EMR that allows for responsible and efficient data entry AND migration of data to subsequent encounters, federal regulators have issued yet another mandate without a clear vision of its implications.  As I stated earlier, I believe EMR is vital for patient information management and will ultimately help us provide more streamlined care that is evidenced based.  Unfortunately, the current EMR systems that are in place do not place a priority on ease of use, efficiency or portability.  Although I am sure that there is some intentional documentation fraud occurring, I would suggest that the majority of physicians and other providers are simply trying to “get the job done” and move on to more important patient care activities.  EMR documentation can be slow and arduous.  During transition phases, many providers report 2-3 extra hours added to their days for documentation activities.  No physician wants to continually take a practice laptop home in order to finish entering EMR notes during family time night after night.  Cloning data is a simple way to carry over information such as medication lists, past medical histories and other information in order to improve efficiency while at the same time providing adequate documentation.  As with most things, this type of data migration is easy to abuse if physicians do not pay special attention to ensure that the migrated data is both accurate and representative of the work that was performed.

As the current administration has clearly demonstrated with the rollout of the  ACA,  as well as with the new ICD-10 coding system and the EMR mandates, sweeping reform that is rushed to completion without a full understanding of its implications is doomed to fail.  Putting politics and power ahead of good sense has resulted in increased cost for these government mandated programs.  As a nation we must certainly work to prevent fraud and abuse as part of our efforts to curtail healthcare costs.  However, as we initiate reforms, we must do a much better job of anticipating issues with new technologies and work to deal with them on the front end–if we do not, we can expect costs to continue to rise.

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3 responses to “The Electronic Medical Record Mandate and Managing Fraud: More Government Ineptness?

  1. So a Common Core type of EMR? Hmmm……:)

  2. As a physician, I entirely agree with your blog post. EMR is essential to decreasing healthcare costs, but the method of implementation results in huge unnecessary costs. This is entirely predictable if our government asks for opinions from physicians in private practice before implementing programs. Physicians in academic programs are outstanding, but we will continue to incur huge preventable costs if private practice doctors are not consulted also. This is important in all aspects of the ACA and there is no way for physicians to help prevent unnecessary complications. I say this as someone who has been very involved with healthcare reform since 2007 as a member of Doctors for America.

  3. Copy/Paste certainly can be an issue in terms of accurate patient documentation as well as accurate billing, but the brief mention of the government’s poor planning probably is closer to the “root cause” of the problem.

    The hurdle which prevented medicine from embracing the EMR from the 1908’s all the way through to the government’s mandate in 2009 was a lack of defined data standards. No players in medicine – physicians, hospitals, or vendors – was willing to sink millions of dollars into an electronic investment if that investment could not subsequently communicate with the rest of the medical world. The “network effect” demonstrated so clearly by Microsoft’s Windows OS was widely understood – except by the government.

    Imagine where we would be with EHRs today if the government had, in 2009, or 2001, or whenever, simply sat down with EMR vendors and worked out a data standard.

    One of the primary events which led to the PC revolution of the 80s was the adoption in the early 70s (late 60s?) by IBM of the ASCII data encoding standard. IBM had originally tried to force the rest of the computing world to accept EBCDIC (which IBM invented and had the rights to) as the standard, but the rest of the computing world feared IBM’s power and used the ANSI to create and adopt ASCII instead, as an open standard. Part of the PC revolution was the plethora of add-on devices, and part of that was the adoption of ASCII as a low cost alternative to EBCDIC.

    Back to EHRs, rather than adopting a data standard as the very first order of business, the government instead focused on the opposite end of the systems, and so we now have “Meaningful Use” standards defining how and why data must be entered, at the expense of sucking all the innovation out of the EHR industry as the vendors struggle to meet standards defined late and poorly, and which STILL cannot be communicated among systems from different vendors.

    5 years of a growing Tower of Babel, no innovation of data input during that period, and now the government is trying to claim fraud because the systems do manage to handle the astoundingly complex details of billing better than human billers/coders ever could. Copy/Paste is a symptom, but inept government interference is the disease.

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